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THE TIME-RELATIONS OF CARDIAC ENLARGEMENT
149
OBJECTS OF SURGICAL ART
and very many readers of the British Journal must have looked forward to acquiring this series of articles in a more permanent form. The reader’s most immediate reaction will probably be one of horror when he considers the amount of money wasted by the prescription of endocrine preparations by mouth which are completely inactive thus given. If the only function of the book were to bring this home to the medical profession it would serve, a useful purpose; but it also provides definite guidance towards rational endocrine therapy, and gives cause for optimism to the most cynical.
disorder
readily produces enlargement
emphasis,
given
Medical
in the young than in the old. Congestive failure is attended by some increase in the heart’s size (though the increase is more apparent than real), and this is a consequence largely of changes in the auricles. On the other hand, no evidence is forthcoming in support of " acute dilatation," which still awaits
TUBERCULOSIS IN INDIA
THE April number of the Indian Medical Gazette is devoted to tuberculosis. In an editorial article it is pointed out that the disease is by no means a recent arrival in India, but one that has claimed victims for many centuries (25 at least, it is believed). To-day, however, it appears to be spreading rapidly and has become a problem of public rather than individual health. The claim is made that the soil on which the tubercle bacillus is implanted in India is entirely different from that anywhere else in the world, though this claim is somewhat modified later on. A set of environmental factors of importance in the West are not necessarily of equal importance in the East, and a public demand for sanatoriums and dispensaries, and all the paraphernalia of Western anti-tuberculosis measures, though well meaning, is not necessarily well advised. The alternatives are not clear, but a plea is made for organised search, both in the field and in the laboratory, for the best methods of combating the disease, and the signed articles in this special number form a useful contribution to the subject. Dr. A. C. Ukil states that tuberculosis is not yet notifiable in the rural areas of India, whilst the registration of deaths is sufficiently defective for many fatal cases of the disease to pass unrecognised. Public health work is therefore beset with difficulties. Nevertheless, the results of sanatorium treatment, recorded in another paper by Dr. Fremodt-Moller, at the Union Mission Sanatorium, show that good results are obtainable with modern methods in India just as in Europe. Other contributions, too, give evidence of alertness in the modern treatment of the disease. THE TIME-RELATIONS OF CARDIAC ENLARGEMENT
RADIOGRAPHY is useful both to establish the presence of heart disease and to reveal its cause. Studies to this end have been concerned more with statics than dynamics and the changing appearances in the course of cardiac disorders are not well known. Dr. Palmer,’- however, has now succeeded in collecting data on the progressive changes in the heart’s size over long periods in a variety of conditions. According to current belief, enlargement depends chiefly on two factors-first, the work that the heart is called upon to do, and secondly, its capacity for doing it. The capacity to perform work is affected by many different kinds of injury to the myocardium, especially ischaemia and chronic inflammation ; but apart from these a hypertrophied myocardium seems to become fatigued and inefficient in a way not well understood. There are probably other factors that contribute to enlargement, and Dr. Palmer suggests that age is one of them ; for a 1 Palmer,
J. H., Development of Cardiac Enlargement in a Radiological Study ; Spec. Rep. Ser. med. Res. Coun. No. 222. H.M. Stationery Office. Pp. 48. 1s. Disease of the Heart:
more
radiological proof. Dr. Palmer, however, draws attention to rapid local increase in the size of the left ventricle, which, if it
within a few months of symptoms, means cardiac aneurysm. It is to be noted that an increase in the cardiac shadow is referred to as enlargement simply, and no attempt is made to distinguish between hypertrophy and dilatation. This is in accordance with opinion nowadays held that there is no such thing as acute enlargement and that the magnitude of the two components of enlargement are hard to assess. Though there are considerable local enlargements which are obvious exceptions to this rule, differentiation, when attempted, is usually based more on inference from the history and symptoms than on the physical signs. Dr. Palmer’s report throws light on a neglected aspect of cardiology, and at the same time shows where further work should be done. and without distinct
occurs
aggravation
OBJECTS OF SURGICAL ART THE museum of the Royal College of Surgeons contains a great many surgical instruments, and of late years the honorary curator of the historical collection has endeavoured to preserve, as a memorial to eminent surgeons, specimens of instruments which they originated and which are known by their names. To the collections thus gathered has now been added a number of the instruments invented and used by the late Lord Moynihan, which have been presented by his son. Another important addition to this section are examples of many interesting patterns of instruments and appliances made by the firm of Down Bros. over a quarter of a century ago. Most of these are now becoming obsolete, for (as the donor points out) very few instruments now remain unchanged for twenty-five years. This large assemblage also serves to show the gradual obsolescence of certain operations and affords material for study by surgeons who are proposing to design new instruments. By the kindness of Dr. R. J. Probyn Williams, the already fine collection illustrating the history of anaesthetic apparatus has been enlarged by a number of pieces dating from 1895 to 1908. The include the original model made for Paterson’s nasal gas apparatus and the original model of the ether inhaler devised by the donor. The history of the head-saw has now been worked out by the honorary curator and the result is shown in a series of these instruments, now mounted, documented, and chronologically arranged in the instrument room. The earliest representation of the head-saw is that figured in a manuscript of the eleventh century by Albucasis. In the fourteenth century there is a drawing of one in the MS. of William of Parma that belonged to John Wryghtson of Oxford, from which a model has been made. In the sixteenth century Andreas Della Croce depicts several with blades of varied shape. After the seventeenth, the head-saw went out of use, until its employment was revived by Cockell about 1783. Cockell devised several instruments with different shaped blades and six of those he originally used are included in the collection. In 1803 the use of the head-saw was again advocated by William Hey,
.,
OBJECTS OF SURGICAL ART
and very many readers of the British Journal must have looked forward to acquiring this series of articles in a more permanent form. The reader’s most immediate reaction will probably be one of horror when he considers the amount of money wasted by the prescription of endocrine preparations by mouth which are completely inactive thus given. If the only function of the book were to bring this home to the medical profession it would serve, a useful purpose; but it also provides definite guidance towards rational endocrine therapy, and gives cause for optimism to the most cynical.
disorder
readily produces enlargement
emphasis,
given
Medical
in the young than in the old. Congestive failure is attended by some increase in the heart’s size (though the increase is more apparent than real), and this is a consequence largely of changes in the auricles. On the other hand, no evidence is forthcoming in support of " acute dilatation," which still awaits
TUBERCULOSIS IN INDIA
THE April number of the Indian Medical Gazette is devoted to tuberculosis. In an editorial article it is pointed out that the disease is by no means a recent arrival in India, but one that has claimed victims for many centuries (25 at least, it is believed). To-day, however, it appears to be spreading rapidly and has become a problem of public rather than individual health. The claim is made that the soil on which the tubercle bacillus is implanted in India is entirely different from that anywhere else in the world, though this claim is somewhat modified later on. A set of environmental factors of importance in the West are not necessarily of equal importance in the East, and a public demand for sanatoriums and dispensaries, and all the paraphernalia of Western anti-tuberculosis measures, though well meaning, is not necessarily well advised. The alternatives are not clear, but a plea is made for organised search, both in the field and in the laboratory, for the best methods of combating the disease, and the signed articles in this special number form a useful contribution to the subject. Dr. A. C. Ukil states that tuberculosis is not yet notifiable in the rural areas of India, whilst the registration of deaths is sufficiently defective for many fatal cases of the disease to pass unrecognised. Public health work is therefore beset with difficulties. Nevertheless, the results of sanatorium treatment, recorded in another paper by Dr. Fremodt-Moller, at the Union Mission Sanatorium, show that good results are obtainable with modern methods in India just as in Europe. Other contributions, too, give evidence of alertness in the modern treatment of the disease. THE TIME-RELATIONS OF CARDIAC ENLARGEMENT
RADIOGRAPHY is useful both to establish the presence of heart disease and to reveal its cause. Studies to this end have been concerned more with statics than dynamics and the changing appearances in the course of cardiac disorders are not well known. Dr. Palmer,’- however, has now succeeded in collecting data on the progressive changes in the heart’s size over long periods in a variety of conditions. According to current belief, enlargement depends chiefly on two factors-first, the work that the heart is called upon to do, and secondly, its capacity for doing it. The capacity to perform work is affected by many different kinds of injury to the myocardium, especially ischaemia and chronic inflammation ; but apart from these a hypertrophied myocardium seems to become fatigued and inefficient in a way not well understood. There are probably other factors that contribute to enlargement, and Dr. Palmer suggests that age is one of them ; for a 1 Palmer,
J. H., Development of Cardiac Enlargement in a Radiological Study ; Spec. Rep. Ser. med. Res. Coun. No. 222. H.M. Stationery Office. Pp. 48. 1s. Disease of the Heart:
more
radiological proof. Dr. Palmer, however, draws attention to rapid local increase in the size of the left ventricle, which, if it
within a few months of symptoms, means cardiac aneurysm. It is to be noted that an increase in the cardiac shadow is referred to as enlargement simply, and no attempt is made to distinguish between hypertrophy and dilatation. This is in accordance with opinion nowadays held that there is no such thing as acute enlargement and that the magnitude of the two components of enlargement are hard to assess. Though there are considerable local enlargements which are obvious exceptions to this rule, differentiation, when attempted, is usually based more on inference from the history and symptoms than on the physical signs. Dr. Palmer’s report throws light on a neglected aspect of cardiology, and at the same time shows where further work should be done. and without distinct
occurs
aggravation
OBJECTS OF SURGICAL ART THE museum of the Royal College of Surgeons contains a great many surgical instruments, and of late years the honorary curator of the historical collection has endeavoured to preserve, as a memorial to eminent surgeons, specimens of instruments which they originated and which are known by their names. To the collections thus gathered has now been added a number of the instruments invented and used by the late Lord Moynihan, which have been presented by his son. Another important addition to this section are examples of many interesting patterns of instruments and appliances made by the firm of Down Bros. over a quarter of a century ago. Most of these are now becoming obsolete, for (as the donor points out) very few instruments now remain unchanged for twenty-five years. This large assemblage also serves to show the gradual obsolescence of certain operations and affords material for study by surgeons who are proposing to design new instruments. By the kindness of Dr. R. J. Probyn Williams, the already fine collection illustrating the history of anaesthetic apparatus has been enlarged by a number of pieces dating from 1895 to 1908. The include the original model made for Paterson’s nasal gas apparatus and the original model of the ether inhaler devised by the donor. The history of the head-saw has now been worked out by the honorary curator and the result is shown in a series of these instruments, now mounted, documented, and chronologically arranged in the instrument room. The earliest representation of the head-saw is that figured in a manuscript of the eleventh century by Albucasis. In the fourteenth century there is a drawing of one in the MS. of William of Parma that belonged to John Wryghtson of Oxford, from which a model has been made. In the sixteenth century Andreas Della Croce depicts several with blades of varied shape. After the seventeenth, the head-saw went out of use, until its employment was revived by Cockell about 1783. Cockell devised several instruments with different shaped blades and six of those he originally used are included in the collection. In 1803 the use of the head-saw was again advocated by William Hey,
.,